The debate over how to define ‘futile’ treatment has hit the headlines again, with a new study showing doctors support the concept but more than half have difficulty coming to a consensus on how to approach it in a clinical setting.
The study, published in the MJA, found that while the term was widely employed, there was some confusion about its meaning and when to invoke it, with many doctors seeking colleagues’ opinions before making decisions.
“Futile medical treatment is a pressing challenge for Australian clinicians and the Australian health system,” the authors wrote. “Futile treatment can prevent a good death and may cause distress to patients and families, as well as moral distress to health professionals.
“Additionally, futile treatment consumes scarce health resources, denying health services to others who could benefit.”
Lead author, Professor Ben White, director of the Australian Centre for Health Law Research, Queensland University of Technology, said the study was part of a wider research project looking at wide ranging issues of futile treatment at the end of life, from legal, policy, sociological and economic perspectives.
He said the study had identified conceptual consistency in how doctors defined futility, even across specialties.
“We were surprised at the high level of consensus,” he told the limbic. “But despite this consensus, a high level of subjectivity was acknowledged too. A very large number of doctors said ‘what I think is futile, another doctor might not’.”
The study involved 96 semi-structured interviews with doctors from three public hospitals in Brisbane, including emergency (15 doctors), intensive care (12), palliative care (10), oncology (10), renal medicine (9), internal medicine (9), respiratory medicine (9), surgery (8), cardiology (5) and geriatrics (5). Four medical administrators were also included.
Seventy of the 96 doctors referred to the probability of achieving a benefit as part of defining futility. Some commented that assessing the chance of benefit is subjective, and referred to considering colleagues’ opinions, patients’ wishes, and other contextual factors.
“We distilled the following definition from the majority of responses, largely using their words,” the authors wrote.
Futile treatment is treatment that has only a very low chance of achieving meaningful benefit for the patient in terms of:
- improving quality of life;
- sufficiently prolonging life of acceptable quality; or
- bringing benefits that outweigh the burdens of treatment.
Despite the high level of conceptual consensus in definitions of futility, doctors differed when applying the term clinically, the authors found, referring to comments by a male renal physician.
“Even within our department we have different views on what is futility. You may think it is futile, but the family may not … So where we draw the line: that is the basic problem. There is a conflict everywhere,” he said.
Professor White said subjectivity seemed to be at the heart of the discourse, and many doctors had tried to overcome this by talking cases through with colleagues as well as patients and families.
“It is a vexed issue that does need addressing,” he said.
In an associated editorial in the MJA, Senior Australian of the Year 2013 and palliative care specialist, Flinders University Emeritus Professor Ian Maddocks AM, suggested the terminology should have a focus on ‘utility’ rather than futility.
“Futility is an absolute term; an intervention is either futile or it is not,” he wrote. “If it is declared futile, a treatment should be suspended. This finality of the decision that a treatment is futile can disturb both doctor and patient.”
He said that the term ‘utility’ could be used throughout all phases of a patient’s prognosis.
“I suggest that, when assessing further management in such situations, “utility” is a more appropriate term than “futility”,” he said.
“Utility is not an absolute; it assesses usefulness over a range of applications and opportunities. An action may be partly useful, assisting one aspect of care but not another, or be temporarily useful, pending further consideration. It also has the advantage of positive intent, relating to what can or will be done rather than what should be avoided. In this sense it follows the suggestion made years ago to replace “not for resuscitation” notes with “good palliative care”.